Health inspection·June 7, 2023

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure pressure relieving interventions were in place for 1 of 5 residents (R7) reviewed for pressure wounds in a sample of 25. Residents Affected - Few The findings include: R7's Facility assessment dated [DATE] showed R7 is a [AGE] year-old female resident with a history of pressure wounds and needing extensive assistance with bed mobility and transfers. On 6/5/23 at 10:45 AM, R7 was lying in bed on her back. R7 stated she had previously broken her leg and has a difficult time moving in bed. R7's heels were resting directly on the mattress with no pillow or offloading device present. R7 stated she had previously had pressure wounds and they took a while to heal. At 1:10 PM R7 was in the same position. On 6/6/23 at 10:45 AM, V13 (Physical Therapist/Wound Team) stated R7 has had wounds in the past. R7's skin is thin and needs to be protected. R7's Braden assessment dated [DATE] showed R7 is at risk for developing pressure wounds. R7's Physician Orders printed on 6/6/23 showed Bilateral heels floating on pillows while in bed every shift. R7's Care plan printed on 6/6/23 showed R7's pressure ulcer development interventions include elevate heels on pillows and follow policies/protocols for the prevention/treatment of skin breakdown. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145706 If continuation sheet Page 2 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145706 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whitehall of Deerfield 300 Waukegan Road Deerfield, IL 60015 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to offer additional pain medication for a resident with pain for 1 (R405) of 25 residents reviewed for pain in the sample of 25. Residents Affected - Few The findings include: 1. R405's Face Sheet shows diagnoses of: Multiple fractures of ribs, left side, and hemothorax. R405's Physician's Order Sheet shows orders for Tylenol extra strength 500 milligrams (MG) every 6 hours as needed for pain and tramadol 50 MG every 6 hours as needed for moderate pain. On 6/5/23 at 10:05 AM, R405 complained of pain at a level 7 on a pain scale of 0-10. R405 said that the pain was located at her back left rib area. V10 (Registered Nurse/RN) gave R405 Tylenol 500 milligrams (MG) for the pain. At 1:45 PM, R405 said that her pain was at a level 7. At that time, V10 entered the room and said that she can only have Tylenol every 6 hours and she just gave her some with her morning medications. V10 did not offer any additional pain medications. R405 was then provided Physical Therapy. On 6/6/23 at 1:05 PM, V8 (RN) said that pain medication is administered per the physician's order. V8 said that if an as needed pain medication is administered, the nurse should re-assess the resident's pain after 45 minutes to ensure that it was effective. If it was not effective, the Medication Administration Record (MAR) should be checked to see if the resident has any additional pain medications that could be administered. If they do not have anything else ordered, the physician needs to be notified. R405's Physical Therapy Notes dated 6/5/23 shows, MOD A (moderate assist) with BLEs (bilateral lower extremities) with back pain complaints Complexities/Barriers Impacting session: L (left) back pain. R405's MAR shows that she did not receive any tramadol on 6/5/23. R405's Pain Care Plan shows, Medicate prior to therapy/treatment Provide analgesic as ordered . The facility's Pain Policy revised on 7/28/22 shows, After the administration of prn (as needed) pain medication, the resident will be assessed for the effectiveness of the pain medication. If the resident is still unrelieved of pain despite pharmacological and nursing measures, the resident's physician will be called to refer the lack of relief. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145706 If continuation sheet Page 3 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145706 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whitehall of Deerfield 300 Waukegan Road Deerfield, IL 60015 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to administer medications at the ordered time and ordered dosage. There were 31 opportunities with 2 errors resulting in a 6.45 % error rate. This applies to 1 of 5 residents (R405) observed in the medication pass. Residents Affected - Few The findings include: 1. R405's June Medication Administration Record (MAR) shows an order for slow-release iron 50 milligrams (MG) daily at 9:00 AM and an order for acyclovir 800 MG five times a day for viral infection for 7 days with a start date of 6/5/23 at 9:00 AM. On 6/5/23 at 10:05 AM, V10 (Licensed Practical Nurse) administered R405 her 9:00 AM medications. V10 administered iron 65 MG and did not administer acyclovir. On 6/6/23 at 1:05 PM, V8 (Registered Nurse) said that all medications should be given at the ordered time (one hour before to one hour after). V8 said that the nurse should verify with the MAR on dosage of all medications before administering. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145706 If continuation sheet Page 4 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145706 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whitehall of Deerfield 300 Waukegan Road Deerfield, IL 60015 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, and record review, the facility failed to follow the facility's menu and recipe for residents on puree diet for eight of eight residents (R21, R22, R27, R43, R50, R72, R82, and R357) reviewed for pureed diets in the sample of 25. The findings include: The facility's Diet Type Report dated 6/7/23 shows R21, R22, R27, R43, R50, R72, R82, and R357 are on a puree texture diet. The facility's Week 1 Daily Spreadsheet shows residents on pureed diets are to receive pureed beef barley soup, pureed turkey, and cheese, pureed hot vegetable, pureed peach cobbler, and two slices of pureed bread. The recipe for pureed beef barley soup shows, Place prepared beef barley soup in food processor and blend to a smooth consistency. The recipe for pureed turkey sandwich, no lettuce/tomato shows, place portion of turkey sandwich filling in food processor with cold milk. Do not add lettuce or tomato. Blend to smooth consistency. On 6/5/23 at 10:30 AM, V7 (Cook) took turkey deli meat and pureed it. V7 added a small amount of hot water to thin out the pureed deli turkey meat. At 10:55 AM, V7 began plating pureed trays. V7 placed pureed turkey, pureed green beans, gravy, pureed dessert, and a cup of pureed beef barley soup. There was no bread option served to residents on pureed diets. On 6/5/23 at 12:00 PM, a pureed tray was requested and tested. There was no pureed bread option. The beef barley soup had no vegetables in it and was a watery consistency. On 6/5/23 at 1:00 PM, V7 said he drained the vegetables out of the beef barley soup and added thickener and mashed potato powder to the broth and that is what was served. V7 said he did not know why the vegetables and broth were not mixed together and served to the residents on pureed diets. V7 said to make the turkey, he pureed the deli turkey meat and added hot water to thin it. V7 said he did not serve a bread option to the residents on the pureed diets. On 6/7/23 at 9:47 AM, V4 (Food Director) said, residents on pureed diet are to receive two slices of soaked bread with pureed turkey. V4 said the beef barley is cooked, then the soup is strained the vegetables are removed. Instant mashed potatoe mix is added to the broth to make it a creamy consistency. V4 said the beef barley soup was not blended with the vegetables. V4 said the pureed beef barley soup should have been similar to nectar consistency. V4 said if recipes are not followed, then it could potentially affect weight loss or weight gain. The facility's Puree Texture Diets policy not dated shows, Puree all foods on daily menu per recipe or residents' choice. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145706 If continuation sheet Page 5 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145706 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whitehall of Deerfield 300 Waukegan Road Deerfield, IL 60015 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm 2. On 6/5/23 at 10:05 AM, R405's room did not have a sign on the door alerting staff that R405 was on isolation. V10 (Licensed Practical Nurse) administered R405 her 9:00 AM medications. V10 was not wearing PPE (Personal Protective Equipment). Residents Affected - Few On 6/5/23 at 2:18 PM, V11 (Wound Nurse) was in R405's room performing a dressing change to R405's left lower back area (previous chest tube insertion site). V11 did not have any PPE on. R405's room did not have a sign up showing that she was on isolation. R405's Nurse Practitioner Notes dated 6/2/23 shows, Noted to have red spots/rash to sacral area . R405's Physician's Orders do not show that a dressing was ordered to cover the red spots/rash. R405's Physician's Orders show that acyclovir for a viral infection was ordered on 6/4/23 to start on 6/5/23 at 9:00 AM. R405's Physician's Orders show that contact precautions for shingles was ordered on 6/5/23 at 2:20 PM. R405's Nurse Practitioner Notes dated 6/5/23 at 2:00 PM shows, rashes to sacral noted with worsening blisters/vesicles, likely shingles, started on acyclovir this morning . On 6/5/23 at 2:41 PM, V12 (Nurse Practitioner) said that she saw R405 on Friday (6/2/23) and thought that she might have shingles on her buttock area. V12 said that she then called on Sunday (6/4/23) and ordered acyclovir to be started to be proactive. V12 said that she looked at the area again today (6/5/23) and it is shingles. On 6/6/23 at 1:12 PM, V9 (Infection Control Licensed Practical Nurse) said that isolation should be started on anyone who is suspected of having shingles or has lesions. V9 said that it was not communicated to her until 6/5/23 that it was suspected that R405 had shingles. On 6/6/23 at 1:12 PM, V3 (Assistant Director of Nursing) said that R405 was started on isolation about 10 minutes before being discharged to the hospital. R405's Change in Condition Form shows that she was sent out to the hospital on 6/5/23 at 2:45 PM. The facility's Infection Prevention and Control Policy revised on 3/10/23 shows, If a resident develops signs or symptoms of infection, the nurse will notify the DON (Director of Nursing) or designee, so that the occurrence of infection can be recorded and monitored . Based on observation, interview, and record review facility staff failed to wear appropriate PPE (personal protective equipment) in a contact isolation room for a resident and failed to place a resident on contact isolation with a suspected shingles outbreak. This applies to 2 of 25 residents (R356, R405) in the sample of 25. The findings include: 1. On 6/5/2023 at 11:50AM, V6 (Certified Nursing Assistant/CNA) was observed in R356's room assisting the R356 out of the bathroom. V6 was observed to be wearing gloves only, with no gown present on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145706 If continuation sheet Page 6 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145706 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whitehall of Deerfield 300 Waukegan Road Deerfield, IL 60015 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few V6. There was a contact isolation sign observed which was posted to the right side of the resident's door. A black cart with isolation supplies was observed to the right of the resident's door blow the contact isolation sign. On 6/5/2023 at 11:56AM, V6 said she was assisting R356 out of the bathroom. V6 said she only had gloves on. V6 said she did not know why R356 was on isolation. V6 said she did not see a sign outside of the resident's room. V6 said gown and gloves should be worn when entering a contact isolation room. On 6/7/2023 at 9:40AM, V2 (Director of Nursing/DON) said staff should wear a gown and gloves when caring for a resident on contact isolation. R356's Order Summary Report as of 6/5/2023 shows an order for isolation - contact precautions, reason for isolation: ESBL (Extended Spectrum Beta-Lactamase) in urine - every shift started on 5/29/2023. The facility's Infection Prevention and Control policy, revised 3/10/23, states . Contact precaution. Use of Gown and gloves is necessary for all interactions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145706 If continuation sheet Page 7 of 7